DIRECTORATE OF HUMAN RESOURCES DIRECTORATE GENERAL OF HIGHER EDUCATION
MINISTRY OF NATIONAL EDUCATION
FORM A (Revised 2008)
A. PERSONAL DATA
1. Full name (capital
letters) : ... (Last name)
... (First name)
2. Gender : Male Female
3. Place & date of birth : ..., .../.../... ....
4. Home address &
Phone No. : ... ... ...
... Pos code : ...
Tel. : (...)... Mobile : ...
5. E-mail address : ... ...
6. Marital status : Single Married
7. Spouse’s
occupation : ... 8. Employment :
University : ... ...
Faculty : ... ...
Department : ... ...
9. Civil service data : NIP : ... ...
(if available)
Karpeg : ... (if available)
10. Rank (Golongan) : ... B. EDUCATION BACKGROUND
1. Please state your university, field of study, and year of degree obtained or non-degree training course(s) attended.
No
. Name of Institution
Year
attended Degree/Certificate Field ofStudy
From To
2. Academic Aptitude Test (Test Potensi Akademik-OTO/Bappenas), if available :
Score Year obtained
3. English proficiency :
International (Official) TOEFL :
Score Year obtained
Pre-TOEFL :
Score Year obtained
Institutional TOEFL :
Score Year obtained
Please indicate (thick) your proficiency in foreign language(s) :
English French German Japanese
Fai r
Good Very good
Fai r
Good Very good
Fai r
Good Very good
Fai r
Good Very good Spoke
n Writte n
C. ACADEMIC BACKGROUND
1. Attach your official copies of English-translated academic transcript . 2. Title of your “sarjana” and M.S. thesis :
Title of “sarjana”
scription : ... ... ...
... ...
Title of master thesis : ... ...
... ...
... ...
3. List of your research projects and your position at the projects mostly related to your proposed study (1. Principal investigator, 2. member, 3. consultant, 4. enumerator, or 5. other)
No. Year Project Title Position
1 2 3
4. List your recent scientific publications published in journals
No. Year Article Title Journal’s name and
place of publication 1
2 3
5. Write names of three academic referees (former advisors, direct academic advisors, etc)
No. Name Relationship Country
1 2 3
D. PRESENT POSITION AND DUTIES
1. Teahing responsibilities . List name of courses taught in the past two years
No. Course Titles
1 2 3 4 5
2. Administrative or other responsibilities :
Year Position
E. PROPOSED STUDY PROGRAM
1. Program : Ph.D.
Master Non Degree
Sandwich Program
2. Field of study : ... ...
3. Main research interest : ... ...
4. Proposed university : ... ...
Name of university : ... ...
Country : ... ...
Name of advisor : ... ...
5. Length of proposed
study : ... years
6. Research proposal : Please attach (separately) your research proposal that has been discussed with or approved by your prospective advisor. Please also provide or attach copies of your communication letters or email to support that a communication with your prospective advisor has been carried out.
Verified by Dean of the Faculty of Date : ...
... ....
NIP. ...
Signature of the candidate
... ...
